Total hip arthroplasty with Boneloc cement: Unsatisfactory results in 163 hips after 9 to 11 years

Cemented Versus Cementless Femoral Fixation for Total Hip Arthroplasty Following Osteoarthritis

BACKGROUND

The mode of femoral fixation for primary total hip arthroplasty (THA) is undetermined, with reported outcomes favoring different fixation methods. This study aimed to compare postoperative complications between cemented and cementless fixation at 90 days, 1 year, and 2 years in patients aged 65 years of age and older undergoing THA for osteoarthritis.

METHODS

Using an all-payer, national database, patients 65 years and older undergoing primary THA, either with cementless (n = 56,701) or cemented (n = 6,283) femoral fixation for osteoarthritis were identified. A 1:1 propensity-matched analysis for age, sex, comorbidity index, alcohol abuse, tobacco use, obesity, and diabetes was performed, resulting in n = 6,283 patients in each cohort. Postoperative outcomes, including postoperative periprosthetic joint infection, aseptic revision, surgical site infection, pulmonary embolism, venous thromboembolism, wound complications, dislocation, periprosthetic fracture, and aseptic loosening were assessed.

RESULTS

The cemented cohort had higher rates of infection (4.5 versus 0.8%, odds ratio [OR] 5.9, 95% confidence interval [CI] 4.33 to 7.93, P < .001), aseptic revision (2.9 versus 2.0%, OR 1.47, 95% CI 1.17 to 1.85, P = .001), venous thromboembolism (1.8 versus 1.3%, OR 1.40, 95% CI 1.05 to 1.87, P < .001), and aseptic loosening (1.5 versus 0.7%, OR 2.31, 95% CI 1.60 to 3.32, P < .001) at 90-days. At 1 and 2 years, the cemented cohort had higher rates of infection, aseptic revision, and aseptic loosening (all P < .001). Rates of periprosthetic fracture were similar at all time points (all P < .001).

CONCLUSIONS

Cemented fixation had higher rates of infection, aseptic loosening, and aseptic revision. This finding supports the current use of cementless fixation, but the ultimate decision regarding fixation type should be based on the proper optimization of the patient's comorbidities and bone quality.

Influence of Fixation Methods on Prosthetic Joint Infection Following Primary Total Knee Replacement: Meta-Analysis of Observational Cohort and Randomised Intervention Studies

The type of fixation used in primary total knee replacement (TKR) may influence the risk of prosthetic joint infection (PJI). We conducted a systematic review and meta-analysis to assess published evidence linking type of fixation (cemented, uncemented, or hybrid) with the risk of PJI following primary TKR. Randomised controlled trials (RCTs) and observational cohort studies comparing fixation methods and reporting PJI incidence following primary TKR were identified in MEDLINE, Embase, Web of Science, and Cochrane Library up until November 2018. Summary measures were relative risks (RR) with 95% confidence intervals (CIs). We identified 32 eligible articles (24 observational studies and 8 RCTs) involving 1,161,292 TKRs. In pooled analysis of observational studies, uncemented fixation was associated with a decreased overall PJI risk when compared with cemented fixation at 0.76 (0.64–0.89). Comparing antibiotic-loaded cemented fixation with plain cement, there was no significant difference in overall PJI risk at 0.95 (0.69–1.31), but PJI risk was increased in the first 6-month postoperative period to 1.65 (1.12–2.43). Limited data from RCTs showed no differences in PJI risk among the fixation types. Observational evidence suggests uncemented fixation may be associated with lower PJI risk in primary TKR when compared with cemented fixation. In the early postoperative period, antibiotic-loaded cemented fixation may be associated with increased PJI risk when compared with plain cement. This may either reflect appropriate selection of higher risk patients for the development of PJI to cemented and antibiotic-loaded cement or may reflect a lower PJI risk in uncemented TKR due to factors such as shorter operative time.

Implant Fixation and Risk of Prosthetic Joint Infection Following Primary Total Hip Replacement: Meta-Analysis of Observational Cohort and Randomised Intervention Studies

Prosthetic joint infection (PJI), although uncommon, is a dreaded and devastating complication of total hip replacement (THR). Whether implant-related factors, such as the fixation method, influences the risk of PJI following THR is contentious. We conducted a systematic review and meta-analysis to evaluate the body of evidence linking fixation methods (cemented, uncemented, hybrid, or reverse hybrid) with the risk of PJI following primary THR. Observational studies and randomised controlled trials (RCTs) comparing fixation methods, and reporting PJI incidence following THR, were identified through MEDLINE, Embase, Web of Science, Cochrane Library, and reference lists of relevant studies up to 24 April 2019. Summary measures were relative risks (RRs) (95% confidence intervals, CIs). We identified 22 eligible articles (based on 11 distinct observational cohort studies comprising 2,260,428 THRs and 4 RCTs comprising 945 THRs). In pooled analyses of observational studies, all cemented fixations (plain and antibiotic combined), plain cemented fixations, hybrid fixations, and reverse hybrid fixations were each associated with an increased overall PJI risk when compared with uncemented fixations: 1.10 (95% CI: 1.04–1.17), 1.50 (95% CI: 1.27–1.77), 1.49 (95% CI: 1.36–1.64), and 1.49 (95% CI: 1.14–1.95), respectively. However, in the first six months, uncemented fixations were associated with increased PJI risk when compared to all cemented fixations. Compared to antibiotic-loaded cemented fixations, plain cemented fixations were associated with an increased PJI risk (1.52; 95% CI: 1.36–1.70). One RCT showed an increased PJI risk comparing plain cemented fixations with antibiotic-loaded cemented fixations. Uncemented and antibiotic-loaded cemented fixations remain options for the prevention of PJI in primary THR.